Elsevier

The Lancet

Volume 391, Issue 10124, 10–16 March 2018, Pages 989-998
The Lancet

Series
Out-of-hospital cardiac arrest: in-hospital intervention strategies

https://doi.org/10.1016/S0140-6736(18)30315-5Get rights and content

Summary

The prognosis after out-of-hospital cardiac arrest (OHCA) has improved in the past few decades because of advances in interventions used outside and in hospital. About half of patients who have OHCA with initial ventricular tachycardia or ventricular fibrillation and who are admitted to hospital in coma after return of spontaneous circulation will survive to discharge with a reasonable neurological status. In this Series paper we discuss in-hospital management of patients with post-cardiac-arrest syndrome. In most patients, the most important in-hospital interventions other than routine intensive care are continuous active treatment (in non-comatose and comatose patients and including circulatory support in selected patients), cooling of core temperature to 32–36°C by targeted temperature management for at least 24 h, immediate coronary angiography with or without percutaneous coronary intervention, and delay of final prognosis until at least 72 h after OHCA. Prognosis should be based on clinical observations and multimodal testing, with focus on no residual sedation.

Introduction

Only about one in ten of all patients with out-of-hospital cardiac arrest (OHCA) will survive,1 but of those who have initial ventricular tachycardia or ventricular fibrillation and who are comatose on admission to hospital after return of spontaneous circulation (ROSC), about half will survive with a reasonable neurological status.2, 3 Historical nihilism towards these patients is, therefore, no longer justified. Whole-body ischaemia and reperfusion in resuscitated patients with OHCA leads to so-called post-cardiac-arrest syndrome.4 This complex combination of pathophysiological processes has four key components: brain injury, myocardial dysfunction, systemic ischaemia and reperfusion response, and the underlying precipitating pathological process that caused the cardiac arrest (table).

The severity of post-cardiac-arrest syndrome after ROSC, and thereby survival and neurological function, varies depending on the severity of the ischaemic insult, the cause of cardiac arrest, out-of-hospital interventions, and the patient's prearrest state of health (figure 1).5 The incidence of serious post-cardiac-arrest syndrome leading to death or unfavourable neurological outcomes at 30 days after OHCA is roughly 36–47% in shockable patients (ie, those with initial ventricular tachycardia or ventricular fibrillation) and 86–89% in non-shockable patients (ie, those with asystole or pulseless electrical activity).5 Important features in the occurrence of post-cardiac-arrest syndrome, therefore, are the initial cardiac rhythm and whether bystander cardiopulmonary resuscitation (CPR) was given. Care after OHCA has improved early mortality due to post-cardiac-arrest syndrome, but short time from arrest to ROSC remains extremely important. Patients who die within 1 day of OHCA mainly do so because of circulatory failure, but the major cause of later death in resuscitated patients in hospital is withdrawal of life support due to severe neurological damage. The in-hospital management of patients with post-cardiac-arrest syndrome is the focus of this Series paper.

Section snippets

How should we initially assess and stabilise patients?

In the early phase after ROSC, myocardial dysfunction and microcirculatory dysfunction from global ischaemia lead to rapid release of toxic enzymes and free radicals into the cerebrospinal fluid and blood. Cerebral and microvascular abnormalities persist while metabolic disorders progress to varying degrees, for which no specific therapy has proven efficacy. Initial stabilisation of resuscitated patients includes sedation when needed (eg, violent or non-cooperative patients in severe distress,

ST-segment elevation on electrocardiogram after resuscitation

Most randomised trials of primary percutaneous coronary intervention for ST-segment elevation myocardial infarction (STEMI) have excluded patients presenting with cardiac arrest. Furthermore, we found no randomised trials of immediate invasive strategies in STEMI patients resuscitated after OHCA. Most studies have been small, single-centre, retrospective, observational series and, therefore, are highly vulnerable to unmeasured confounders and selection or reporting biases (appendix).13, 14, 15,

Can we protect the brain?

Targeted temperature management has been the cornerstone of neuroprotection in patients resuscitated but comatose after OHCA for the past 15 years. The exact mechanism of action is unknown. Experimental data suggest that targeted temperature management suppresses pathways leading to delayed cell death and decreases the cerebral metabolic rate, and consequently reduces the release of excitatory aminoacids and free radicals.7 Neither animal studies45 nor observational data from a randomised trial

When and how should we assess the neurological prognosis?

Most patients with OHCA who die after hospital admission while in a coma after resuscitation do so from neurological injury and active withdrawal of life-sustaining treatment.66 Reaching a valid neurological prognosis is, therefore, extremely important. Bilateral absence of corneal and pupillary light reflex at 72 h from ROSC predicts poor outcome with high specificity but low sensitivity. Likewise, a status myoclonus within 48 h from ROSC is associated with a poor outcome, but in these

Should there be cardiac arrest centres?

The final link in the chain of survival after OHCA is increasingly being seen as the next real opportunity to improve long-term survival. In 2010, the American Heart Association published a policy statement supporting the idea of regional systems of care for OHCA.76 Recognising the success of public health initiatives, such as regional systems of care for STEMI and trauma, this statement strongly supported development of similar regional systems for OHCA patients resuscitated out of hospital.

What will we learn in the near future?

Several ongoing randomised clinical trials are comparing subacute or immediate coronary angiography with delayed coronary angiography in patients with OHCA but without ST-segment elevation (NCT02387398, NCT02641626, NCT02750462, and NCT02876458). Randomised trials are also assessing extracorporeal CPR started out of hospital (NCT02527031) and in hospital (NCT03101787 and NCT01511666) for patients with no ROSC after OHCA. Optimum haemodynamic goals after achieving ROSC might be clarified from

Conclusions

Survival after OHCA remains low. Immediate bystander resuscitation, ROSC, and a clear treatable cardiac cause are the best markers of a positive outcome. Immediate echocardiography on arrival at hospital can help to identify possible causes and aid triage of patients. Patients with ECG evidence of ST-segment elevation on arrival at hospital should usually go directly for coronary angiography unless they have severe adverse markers relating to acid-base balance. In patients without ST-segment

Search strategy and selection criteria

We searched the Cochrane Library without date restrictions and MEDLINE for papers published in the past 10 years. We used the search term “out of hospital cardiac arrest” to identify papers with this phrase in the title. We largely selected those published in the past 5 years, but did not exclude commonly referenced and highly regarded older publications. We also searched the reference lists of articles identified by this search strategy and selected those we judged to be relevant.

References (84)

  • N Ito et al.

    Noninvasive regional cerebral oxygen saturation for neurological prognostication of patients with out-of-hospital cardiac arrest: a prospective multicenter observational study

    Resuscitation

    (2014)
  • LM Batista et al.

    Feasibility and safety of combined percutaneous coronary intervention and therapeutic hypothermia following cardiac arrest

    Resuscitation

    (2010)
  • R Knafelj et al.

    Primary percutaneous coronary intervention and mild induced hypothermia in comatose survivors of ventricular fibrillation with ST-elevation acute myocardial infarction

    Resuscitation

    (2007)
  • D Penela et al.

    Hypothermia in acute coronary syndrome: brain salvage versus stent thrombosis?

    J Am Coll Cardiol

    (2013)
  • J Joffre et al.

    Stent thrombosis: an increased adverse event after angioplasty following resuscitated cardiac arrest

    Resuscitation

    (2014)
  • K Ibrahim et al.

    High rates of prasugrel and ticagrelor non-responder in patients treated with therapeutic hypothermia after cardiac arrest

    Resuscitation

    (2014)
  • TW Bjelland et al.

    Antiplatelet effect of clopidogrel is reduced in patients treated with therapeutic hypothermia after cardiac arrest

    Resuscitation

    (2010)
  • P Radsel et al.

    Angiographic characteristics of coronary disease and postresuscitation electrocardiograms in patients with aborted cardiac arrest outside a hospital

    Am J Cardiol

    (2011)
  • K Sunde et al.

    Implementation of a standardised treatment protocol for post resuscitation care after out-of-hospital cardiac arrest

    Resuscitation

    (2007)
  • JM Larsen et al.

    Acute coronary angiography in patients resuscitated from out-of-hospital cardiac arrest—a systematic review and meta-analysis

    Resuscitation

    (2012)
  • AC Camuglia et al.

    Cardiac catheterization is associated with superior outcomes for survivors of out of hospital cardiac arrest: review and meta-analysis

    Resuscitation

    (2014)
  • MG Millin et al.

    Patients without ST elevation after return of spontaneous circulation may benefit from emergent percutaneous intervention: a systematic review and meta-analysis

    Resuscitation

    (2016)
  • J Bro-Jeppesen et al.

    The inflammatory response after out-of-hospital cardiac arrest is not modified by targeted temperature management at 33°C or 36°C

    Resuscitation

    (2014)
  • M Wanscher et al.

    Outcome of accidental hypothermia with or without circulatory arrest: experience from the Danish Praesto Fjord boating accident

    Resuscitation

    (2012)
  • J Bro-Jeppesen et al.

    Post-hypothermia fever is associated with increased mortality after out-of-hospital cardiac arrest

    Resuscitation

    (2013)
  • A Cariou et al.

    Early high-dose erythropoietin therapy after out-of-hospital cardiac arrest: a multicenter, randomized controlled trial

    J Am Coll Cardiol

    (2016)
  • I Dragancea et al.

    Protocol-driven neurological prognostication and withdrawal of life-sustaining therapy after cardiac arrest and targeted temperature management

    Resuscitation

    (2017)
  • RB Metter et al.

    Association between a quantitative CT scan measure of brain edema and outcome after cardiac arrest

    Resuscitation

    (2011)
  • S Langkjaer et al.

    Prognostic value of reduced discrimination and oedema on cerebral computed tomography in a daily clinical cohort of out-of-hospital cardiac arrest patients

    Resuscitation

    (2015)
  • CS Youn et al.

    Repeated diffusion weighted imaging in comatose cardiac arrest patients with therapeutic hypothermia

    Resuscitation

    (2015)
  • P Stammet et al.

    Neuron-specific enolase as a predictor of death or poor neurological outcome after out-of-hospital cardiac arrest and targeted temperature management at 33°C and 36°C

    J Am Coll Cardiol

    (2015)
  • H Soholm et al.

    Tertiary centres have improved survival compared to other hospitals in the Copenhagen area after out-of-hospital cardiac arrest

    Resuscitation

    (2013)
  • D Erlinge et al.

    Rapid endovascular catheter core cooling combined with cold saline as an adjunct to percutaneous coronary intervention for the treatment of acute myocardial infarction. The CHILL-MI trial: a randomized controlled study of the use of central venous catheter core cooling combined with cold saline as an adjunct to percutaneous coronary intervention for the treatment of acute myocardial infarction

    J Am Coll Cardiol

    (2014)
  • M Wissenberg et al.

    Association of national initiatives to improve cardiac arrest management with rates of bystander intervention and patient survival after out-of-hospital cardiac arrest

    JAMA

    (2013)
  • T Cronberg et al.

    Neurologic function and health-related quality of life in patients following targeted temperature management at 33°C versus 36°C after out-of-hospital cardiac arrest: a randomized clinical trial

    JAMA Neurol

    (2015)
  • D Stub et al.

    Post cardiac arrest syndrome: a review of therapeutic strategies

    Circulation

    (2011)
  • K Nagao et al.

    Duration of prehospital resuscitation efforts after out-of-hospital cardiac arrest

    Circulation

    (2016)
  • CW Callaway et al.

    Part 8: post-cardiac arrest care: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care

    Circulation

    (2015)
  • I Salam et al.

    Editor's choice—is the pre-hospital ECG after out-of-hospital cardiac arrest accurate for the diagnosis of ST-elevation myocardial infarction?

    Eur Heart J Acute Cardiovasc Care

    (2016)
  • H Thiele et al.

    Intraaortic balloon support for myocardial infarction with cardiogenic shock

    N Engl J Med

    (2012)
  • E Westhall et al.

    Standardized EEG interpretation accurately predicts prognosis after cardiac arrest

    Neurology

    (2016)
  • P Garot et al.

    Six-month outcome of emergency percutaneous coronary intervention in resuscitated patients after cardiac arrest complicating ST-elevation myocardial infarction

    Circulation

    (2007)
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